Diana Ramos, MD, on exploring the disproportionate impact on the Latinx community

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

In recognition of Hispanic Heritage Month, AMA and health experts discuss the disproportionate impact of COVID-19 on the Latinx community, the impact of the public charge rule, patients' fears and their lack of access to technology.

Learn more at the AMA COVID-19 resource center.

Speakers

• Diana Ramos, MD, adjunct associate professor, Obstetrics & Gynecology, Keck USC School of Medicine
• Ricardo Correa, MD, diversity director, GME, University of Arizona COllege of Medicine
• Veronica Alvarez-Galiana, MD, medical director, OB/GYN services, Community Health of South Florida

Unger: Hello, this is the American Medical Association's COVID-19 Update. In recognition of National Hispanic Heritage Month, today we're discussing the impact of COVID-19 on the Latinx community. I'm joined today by Dr. Veronica Alvarez-Galiana, medical director for OB-GYN services at Community Health of South Florida in Miami. Dr. Alvarez-Galiana is an alternate delegate for the ACOG delegation to the AMA. Dr. Diana Ramos, adjunct associate professor, obstetrics and gynecology at Keck USC School of Medicine in Los Angeles. Dr. Ramos is a delegate and co-chair for the ACOG delegation to the AMA.

Dr. Riccardo Correa, program director of endocrinology fellowship and the diversity director GME at the University of Arizona College of Medicine in Phoenix, Arizona. Dr. Correa is also a delegate of the AMA's IMG Section Governing Council. I'm Todd Unger, AMH Chief Experience Officer in Chicago. All right Dr. Ramos, we're going to start with you, the Latinx community was initially one of those hit hardest by COVID-19. Seven months later, we're still seeing a disproportionate impact. Can you talk about that?

Dr. Ramos: Yes, Todd. Unfortunately, the Latinx community is oftentimes in that category of employment that is considered essential workers. We are the ones that are working in agriculture, in housekeeping, the medical assistants and many of these jobs are not able to be done remotely and so that's one of the contributing factors. The other contributing factor is that many of us live in multiple families in one household. I had one patient this past weekend that had nine people living in her household.

These are some of the things that are contributing. The other big thing is economics. If you don't work and you're not there in person, you don't get paid. All of these things contribute along with the fact that there's a lot of underlying medical conditions, pre-existing medical conditions that once infected a patient can actually have worse outcomes.

Unger: Dr. Correa.

Dr. Correa: Yes. So very important that something that we have seen besides what Dr. Ramos mentioned is that we have been having some disparities that has been underlying from the past. This is nothing new. We know that underrepresented minorities have less access to health care systems. The only thing is that COVID just flourished that and we are seeing that these people that have more chronic disease because they have less access to the newest medication or less access to the health care systems, now they are already sick and then they are getting an infection that just flourishes that sickness.

The inflammation that is being caused, for example, what I'm seeing in diabetes is that there is an increased insulin resistance, meaning that just your insulin requirement gets so high, even in Type 2 diabetes, that your insulin requirement gets so high and then you get a lot of other complications. Besides all of the things that we have to do as a Latino community that you have to be here in the front line, you also have underlying conditions that you were not taking care of because of many other reasons of social determinant of health and now COVID just flourished that.

Unger: That theme of COVID making everything that was already bad, worse, is a consistent one. Dr. Alvarez-Galiana, is this what you're seeing in your practice?

Dr. Alvarez-Galiana: Absolutely. I will add also that we have a lot of migrant workers in our community and patients that don't have insurance or they are green card holders. And so because of the public charge rule, they're also less likely to be coming to our clinics, requesting assistance because they are scared about the consequences of that. Although there has been a little bit of talk about this not affecting patients who have COVID, the patients are already are losing trust in the system and it really affects issues in terms of prevention of chronic diseases and the disparities that were already discussed and then also the spread of disease.

Unger: That's a really important topic. These basically, access to care issues and the barriers that have been exacerbated by COVID-19. Dr. Correa do you have anything to add to that?

Dr. Correa: Yes, Todd. Now that Dr. Alvarez mentioned about the public charge rule, this is something very important that I don't know if everybody's aware of this. I think that the physician community and the entire community should be aware. One month before COVID hits the US, there was a rule that was established by this administration, where people that are in the process of getting some type of permanent status in the US. If they are using any of the federal funding, Medicaid, any of the federal funding, they will be "dinged" so the process cannot continue.

This was a big issue at the beginning because COVID hit and then people were, of course, were afraid. Even they were sick at home and not just because of COVID, sick because their heart failure. Dying from heart failure at home, dying from all of these, they didn't want to go to the hospital. Then there was a pause. The president came and said, "Well, public charge rule will not affect COVID people." Okay, that's fine.

In August of this year, he eliminated again and he said public charge rule is again in rule. Now we are back to zero, nobody knows this and again the immigrant community, and we're not talking about illegal immigrants because everybody's say, "Ah, illegally." No, we're talking about legal immigrants that are looking for permanent status don't want to go to their physicians or get health care because they feel afraid.

Unger: I'm curious in your practices, that's a big challenge, clearly. What do you do to inspire trust and to work through barriers that are like that? Dr. Correa what do you think?

Dr. Correa: One of the things is that I volunteer, and this is the main place where I see my Latino patients. I volunteer in a clinic where we serve undocumented immigrants, and then we really don't care if they have insurance or not. What we are trying to do is just provide care to them. This helped me in the sense that we are just being funded by grants by anonymous people that want to help the community and that's the way that we get. Sometimes we get some pharmaceutical support when medication [is about to] expire, they send that to us and that's the way that we try to survive.

In that setting, we try to do that and we are in a safe zone where all, everybody knows that the clinic is there and there is more trust because this clinic has been there for a long time. We have had certain incidents in the last six months, with having some police outside the clinic. Why the police have to be outside the clinic? We don't know, so we have to call our representative that is in the Latino Caucus and they have to come and then talk to the police leaders and say something.

The other incident that we had was in our testing center there were ICE cars outside the testing center. Why ice is outside of the testing center that has nothing to do with public health? We also have to call, thank God, we have some very strong Latino Caucus in the Congress, in Arizona, and they immediately started calling their contacts and that was destroyed.

But, yes. But then even the community trusts you, seeing this, then you have to gain their trust again. And this is something that should not happen because this a public health problem that is not affecting only undocumented people, it will affect the entire American people. If these people get sick, the entire American people will get sick.

Unger: Dr. Alvarez-Galiana, both you and Dr. Ramos are OB-GYNs. What issues are you seeing with Latinx women in particular during COVID-19?

Dr. Alvarez-Galiana: Well, for Latinx women, everything has become more difficult and especially for pregnant women who already are generally a population that are isolated in the sense of they're working, even though they're pregnant, working very hard usually in these frontline jobs and trying to avoid any kind of infection especially from COVID so these patients are feeling lonely. I've had a lot more incidences of postpartum depression and intrapartum depression so I've noticed that as well, especially amongst my patients who are majority Latinx patients.

They're scared to even come to the hospital. Sometimes they are asking about home births and we have had conversations with them about the safety precautions that we've taken in our hospitals so that has improved over time in terms of the fear that patients have but I believe that it's been a very isolating event for many pregnant women.

Unger: Dr. Ramos anything to add to that?

Dr. Ramos: Yeah, definitely. Yes, there is a lot of fear in terms of showing up and perhaps getting infected by going to their prenatal care appointments, as well as Dr. Galiana said, delivery, that you're going to get COVID in the hospital. The other thing to consider is that many practices are actually doing remote or telemedicine but then this, again, exposes the disparities that have already been existing and some of that is a lack of access to the internet, something as simple as that, that will be able to do a visual, a telemedicine that involves a camera, that's not always available for Hispanic patients.

The other thing too is that many of those appointments tend to be phone calls when there is no internet access. And yes, there is an audio appointment but you miss so much when you don't have the visual component. You can actually see what a patient is, what their environment is, is it neat, is she disheveled, are there symptoms of depression that you can actually see clinically? All of these things contribute to, again, continued disparities.

Then the other thing too is with the children and just reminding patients to continue the preventive care such as immunization, especially right now for influenza, not only for themselves but for their children. Again, that lack of trust that they're going to get infected if they go into an office that they may acquire COVID, keeps folks away from getting that preventive care that can actually help save a life.

Unger: Well, communication is a big issue and I think you're pointing out that. I mean, we're heading into the fall right now where preventive care like flu shots are incredibly important. What are the ways that you all work to improve communications and address these kinds of messaging challenges that affect the Latinx population during the pandemic? Dr. Alvarez-Galiana will you start?

Dr. Alvarez-Galiana: Yes. We come together as a team in our clinic starting from the top down about communicating with patients through our marketing, we send them text messages to remind them of their appointments and also if they're having telemedicine appointments, we can communicate through there. The front desk, the nurses, we all try to create a welcoming environment for the patients. We are screening everyone who comes in through the door so patients are aware that we are taking safety precautions to prevent the spread of COVID-19. Just communicating with patients and open-end communication is also very important when you're seeing a patient in the visit to make sure that you're answering all the questions and concerns that they have.

Unger: Any other thoughts Dr. Correa or Dr. Ramos?

Dr. Correa: Something that we have utilized is champions from the community. It depends on the setting that you are [in]. When you're in a community care center where you are involved in the community, you always can find champions that are people from the community, not health care workers, but people from the community that are very interested in this. We try to prepare those patients so they can spread the real facts of what is happening through their neighbors and then try spreading the things.

Because at the beginning, we were having a lot of, not scientific evidence, and I'm not telling about the hydroxychloroquine and things like that. I'm talking about what my abuelita [grandmother] said that was drinking hot tea to kill the virus and then you get burned and then you have to go to the ER and there was worst. Then trying to educate the community because in the Latino community, there is a lot of trust in the elderly and the elderly, what they say is what you do.

But no one during this generation has seen this Coronavirus so there is nothing. We have to educate those champions who are just going into the community and then trying to clarify. We train them a little bit with some pamphlets, with some lectures, small, but they were the ones that were spreading also the word.

Unger: Well, that that kind of worked Dr. Correa and maybe that is one of the reasons that you are recently named as one of the hundred inspiring Hispanic Latinx Scientists in America. How do we do better with welcoming diversity into the scientific community and how does diversity in the physician workforce influence the care for underserved populations?

Dr. Correa: I think that something that has been ongoing, this group that published this list also published a list, I think at the beginning of the year on black African-Americans scientists and physicians. Is to make the entire country that science does not look only at one race or ethnicity. Science is diverse and many people from different backgrounds are contributing to the US in many things.

Then bringing different people from different backgrounds and demonstrating that they are making some changes in their communities in science, in general, in medicine, in general - I think that can create a conscious to the community, scientific community, and to the general public that really there's many people that are contributing here and it's not just one group. That is something that I think that is very important.

The other part that is important is that when you think about people from diverse backgrounds, you just focus on, okay, are these originally from the US or that they immigrant from the US. They are in the US and they want to contribute to this country. They embrace this country as their country and they give everything that they can to this country and help the communities that they are serving. If this is an African-American black community, they will embrace, they will help that.

This is a Hispanic Latino community, they will help that. That's something that was very inspiring seeing these two lists and this will continue, this is the first year that they are doing this, but this will continue just to make people realize that there is a lot of people from diverse background doing a lot of things for America and many people need to know about this.

Unger: Well, last question for the three of you for a quick round here. When you look at the disparities that have long been affecting the Latinx community and you look at how COVID has exacerbated this, are there any opportunities that you see right now coming out of this situation to improve that, Dr. Ramos?

Dr. Ramos: Yeah, I think COVID has exposed what we already knew was wrong, all the disparities and so with that we have to step up and take into consideration population health. Because if you look at the numbers, we are going to be Hispanics, the majority, by 2050 and so the whole country's health is going to be driven by our health. Whether you're here legally, illegally and preventive health and really trying to build up everyone's health is going to be critical. Taking into consideration wherever they live, whatever their access is.

It's an opportunity for us to come up with solutions and more importantly, involve the community to help us identify the solutions to improve the health, not only of Hispanics, but of everyone. I see it as a green light to start focusing on improving the health of Hispanics as well as everyone else because we're going to drive up the health of the country.

Unger: Well, those are important points and I think that's a good place for us to stop for today. This concludes our COVID-19 episode and I want to thank Dr. Alvarez-Galiana, Dr. Ramos and Dr. Correa for being here today and sharing your perspectives. We'll be back soon with another COVID-19 update. For updated resources on COVID-19, visit ama-assn.org/COVID-19. Thanks for joining us and please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.